1
Q
What does ARM stand for?
A
Artificial rupture of membranes
2
Q
What does EFM stand for?
A
Electronic field monitoring– this is the belt around the belly used to monitor fetal condition
3
Q
what is fFn?
A
Fetal Fibrinectin. This is a test used to establish likelihood of labour in the next 2 weeks. If +ve, we know that mom is likely to go into labour within the next 7 days. If -ve, babe will likely stay in utero for the next 14 days.
4
Q
What is a non-stress test?
A
A test completed during pregnancy to observe how the baby is handling activity ie when mom exerts herself
5
Q
What does “station” refer to?
A
baby’s head in relation to the ischial spine. Right at the ischial spine = 0
6
Q
What is effacement?
A
Thinning of the cervix
7
Q
How is effacement different in a primip as compared to a multip?
A
P- effacement happens before the cervix opens,
M- effacement and opening occurs simultaneously
8
Q
What gestational age is considered “pre-term”?
A
36 weeks + 6 days
9
Q
What is considered “full term”?
A
37 weeks - 41 weeks + 6 days
10
Q
What is considered “post term”?
A
42 weeks +
11
Q
In order to be officially “in labour”, mum must be having what 3 things?
A
4 contractions q20mins, needs to be 2cm dilated, and 80% effaced
12
Q
What puts mom at risk for experiencing pre-term labour? (Demographic, physical, preg. problems, DOH)
A
Demo: age, low SE status, ethnicity
physical: hx of pre term labour, genetics, uterine/cervical or placenta abnormalities
preg.:PROM, fetal anomalies, hydramnious, HIP
DOH: tobacco/drug use, inadequate weight gain, poor nutrition, stress
13
Q
What is the significance of using nifedipine when a mom is at risk for experiencing pre-term labour?
A
it is a calcium channel blocker, and therefore works by inhibiting contraction of smooth muscle, which stops contraction of the uterus, slowing down labour
14
Q
What is the role of progesterone injections for those at risk for pre-term labour?
A
projesterone is a hormone that causes the uterus to relax, which can help slow labour down
15
Q
When is is appropriate to administer tocolytic medications to a mom at risk for pre-term labour?
A
up to 32-33 weeks
16
Q
What is the goal for administering corticosteroids to moms at risk for delivering pre-term babes?
A
help to promote lung development in the babe to help reduce the risk for respiratory distress syndrome in premie babes. *DO NOT GIVE if >34 weeks
17
Q
If your patient starts to go into premature labour, describe the necessary nursing care,
A
- assess contractions and per-vagina loss
- monitor babe
- Assess for side effects of meds
- Give corticosteroids (per MAR) to increase lung maturity of babe
- Prepare for premature birth, including phoning to NICU to advise
18
Q
What are some possible causes for moms going post-term?
A
- error in determining ovulation and conception
- deficiency in placental estrogen (this causes a subsequent decrease in prostaglandin and decrease in oxytocin receptors in myometrium)
- continued secretion of progesterone
19
Q
what are some potential MATERNAL problems when anticipating a post-term delivery?
A
- psychological stress
- induction
- shoulder dystocia
- assisted deliver
- perineal trauma (large babe)
- increased risk of infection and hemorrhage
- risk for c section
- risk for DVT
20
Q
What are some potential FETAL complications with post-term deliveries?
A
- decreased placenta profusion
- fetal demise
- oligohydramnious
- macrosomia (lg babe)
- meconium aspiration
- low apgar
- SIDS
- cerebral palsy
21
Q
If your patient is 41 weeks pregnant, what sort of medical interventions should they expect before the baby comes?
A
- daily fetal movement counts
- bi-weekly non-stress tests
- ultrasound for fetal size and amniotic fluid index
22
Q
Why, based on moms condition, might the doctor consider inducing mom?
A
- post term
- diabetes
- HIP
- PROM
- chorioamnionitis
- previous precipitous L&D
23
Q
Why, based on babes condition, might the doctor consider inducing mom?
A
- demise
- hemolytic disease
- macrosomia (lg babe)
- mild abruptio placenta
24
Q
When considering induction, what scoring tool is used? What is the difference between a “ripe” cerix and an “unripe” cervix?
A
Bishops score
Ripe= >6
Unripe= <6
25
If cervix is unripe, what are some medical interventions to help promote cervical effacement?
- intracervical prostaglandins
- cervidil
- cervical ripening balloon
26
If cervix is ripe, what are some medical intervention to help induction?
- membrane sweep
- amniotomy (break the water)
- intravaginal prostaglandin or IV oxytocin
27
How does a ripening balloon work?
like a foley, insert it, expand it, and it disrupts the cervix because it causes natural secretion of prostaglandins (same idea as having sex)
28
After your patient has been induced, what is the expected nursing care?
1. Baseline assessment (vs, vaginal exam, electronic fetal monitoring)
2. *Follow dr orders re: protocol*
3. Assess pr and
fetus q 2 hrs
4. if cervidil/prostaglandins, pt may be sent home until active labour begins
29
What is the difference between augmentation and induction?
A-occurs when mom is in active labour but is experiencing ineffective contractions
I- occurs when drugs are given to help promote or bring on labour
30
Artificial rupture of the membranes can be very effective in helping promote active labour, but it also comes with some risks. What are these?
- may shorten labour, possibly increasing the risk of tearing
- increased pressure on the head of the baby
- may increase the risk of infection
- increased risk for emergency c-section
31
While monitoring the baby, you notice a decrease in baby's O2. What could possibly be causing this?
- cord compression
| - placenta insufficiency
32
What are some warning signs for fetal distress?
meconium stained liquid is OMINOUS-- obserce fetal heart rate patterns
33
When your baby is in distress, what are the most appropriate nursing actions?
* Stay calm*
1. d/c induction
2. change position to lateral
3. IV bolus
4. Vaginal Exam
5. O2 PRN
6. decrease maternal anxiety
7. fetal scalp blood sample
34
Forceps and Vacuum extraction is only appropriate for what stage of labour and delivery?
2nd
35
Why might Doc consider forceps or vacuum delivery?
MOM- exhaustion, lack of progress, health conditions, decreased motor function with epidural
BABE- distress, placenta separation, OP position (face up), large baby, breech
36
What are the risks for the mom when undergoing forceps delivery?
- laceration
- hematoma
- pressure and pain
- increased bleeding
37
What are the risks for the baby when Dr. uses forceps delivery?
- echymosis/bruising
- edema
- caput cephalohematoma
- paralysis
* *Always inspect perineum and head for complications
38
Why have the rates of Caesarean delivery gone up over time?
- delayed childbearing, which increases risk for complications
- obesity
- decreased number of midwives
- decreased skill with breech deliveries
- personal requests
- inductions
39
What are some sure indications for c-section delivery?
- placenta previa
- placenta abruptio
- prolapsed cord
- CPD (large head)
- active herpes
- babe in wrong position
- failure to progress
- fetal distress
40
When completing a c-section, there are a number of different types of incisions. List these.
**LOOK THIS UP**
Uterine cut- either Kerr (transverse) or sellheim (vertical)
Classic Incision (RARE)- on corpus of uterus
Skin cut- transverse or vertical
41
What are the benefits/disadvantages to using general anesthetic when performing a c-section?
B- quick to administer
| D-depresses fetal CNS, increases blood loss, maternal vomiting, depressed GI motilitiy
42
What are the benefits of using regional anesthesia/analgesia for c-section and vaginal deliveries?
B-mom is conscious, alters motor and sensory function to successfully block pain, prolongs pain relief after c-section
43
Compare and contrast Spinal analgesia vs epidural analgesia
SPINAL-immediate relief, small amount of drug is used, pain relief lasts for 24 hrs after c-section, BUT, headaches are common dt CSF leak, and decreased BP can cause fetal distress
EPIDURAL- does relieve pain for vaginal deliveries, BUT it takes 30 mins to work, more drugs are required, and hypotension can still cause distress
44
What are the main benefits of using combined spinal-epidural block in labour and delivery?
-can be successful for both VD and CD, preserves motor function, small amount of drugs used
45
VBAC are becoming more popular. Unfortunately, they are contraindicated in some cases. What are these?
previous "classic" incision or T uterine incision with previous c-section, as this increases the risk for rupture
46
There is increased monitoring in place for VBAC deliveries. What does this include?
- frequent monitoring
- Electronic field monitoring
- vital signs
- pain over incision site
47
What is umbilical cord prolapse?
when the cord precedes the baby
48
List some factors that increase the risk for umbilical cord prolapse
polyhydramnious
- long cord
- breech
49
What is your course of action when you realize you patient is delivering with a prolapsed umbilical cord?
1. Call Code
2. knee to chest/modified sims/trendelenburg position
3. Hand in vagina to keep pressure off the cord, wrap the cord
4. give O2
5. start IV
6. prepare for delivery
50
What is shoulder dystocia?
when, after delivery of the head, further expulsion of the infant is prevented due to impaction of the fetal shoulders in the maternal pelvis
51
What are the risk factors associated with shoulder dystocia?
- fetal macrosomia
- maternal diabetes
- maternal obesity
- multiparity
- post term babes
52
What does ALARMER stand for? When is it activated?
```
it is a mnemonic used to remember the protocol in place for responding to shoulder shoulder dystocia
A- ask for help
L-lift/hyperflex pts hips
A- anterior shoulder disimpaction
R-rotation of the posterior shoulder
M-Manual removal of the posterior shoulder
E-Episiotomy
R-Roll mom onto all fours
```
53
What is McRobert's maneuver?
when you lift or hyperflex a patient's hips to help promote labour and delivery
54
What are some potential complications that come along with shoulder dystocia?
Mom- post partum hemorrhage, trauma, infection
| Babe- brachial plexus injury, fractures, asphyxia, neurological damage or demise
55
What constitutes a precipitous labour?
labour that occurs in less than 3 hrs
56
What are some contributing factors for precipitous labour?
- multiparity
- large pelvis
- previous precipitous labour
- small fetus
57
How does a precipitous labour affect mom? Babe?
- lacerations/tearing
- poorer coping
- postpartum hemorrhage
-fetal distress, cerebral/nerve trauma in babe
58
What is a precipitous delivery?
delivery that occurs in an unexpected locations ie taxi or elevator or car
59
How much blood must mom lose in order for us to consider it a hemorrhage?
Vaginal >500mls
| C-section >1000 mls
60
What is the best medical practice for avoiding postpartum hemorrhage?
give oxytocin/syntocin after birth for all mothers
61
What is the difference between early and late postpartum hemorrhage?
Early: during 3 or 4 stage or first 24hrs
Late: 24hrs to 6 weeks after delivery (usually 1-2 weeks)
62
What are the 4 T's of hemorrhage?
Tone (decreased uterine tone)
Trauma (lacerations of genital tract)
Tissue (retained placenta or membranes)
Thrombin (coagulation problems)
63
The best way to treat postpartum hemorrhage is to be proactive in avoiding it. What are some associated factors that could help you predict increased risk for hemorrhage?
- overdistension of uterus
- grand multiparity
- anesthetics
- prolonged or rapid labour
- induction/augmentation
- distended bladder
- hx of postpartum hemorrhage
- uterine surgery
- HIP
- anemia, infection
64
What are some proactive actions you can take as a nurse to prepare for a possible postpartum hemorrhage?
- avoid traumatic procedures
- start IV
- cross match
- assess frequently
- pt to void q2-3 hrs
65
If your patient starts to hemorrhage, what do you do?
1. massage uterus
2. Express clots
3. apply pressure
4. give oxytoxic drugs (IM/IV)
66
What are the appropriate medical interventions for uterine rupture?
*GET HELP-CODE OB
-MD to explore uterine cavity and genital tract
-may perform uterine compression
based on dr preference:
-repair lacerations, remove tissue, pack, ligate,
*Last resort = hysterectomy
67
There are 4 degrees of perineal tearing. Explain these.
1- perineal skin, vaginal mucosa
2-plus fascia, muscles of perineal body
3-plus anal sphincter
4-plus rectal mucosa to lumen of rectum
68
If your patient experiences an early PPH with retained products, how will the HCP intervene?
- methylergonovine/ cytotec
- exploration
- manual removal of products
69
If your patient experiences a LATE PPH, how might they present? What causes this?
- lochia rubra >2weeks
| - abnormal involution r/t retained products or infection
70
How are late PPH treated?
Retained products: methylergonovine
| Infection: Abx
71
List some potential sites of infection in the PP mom
- perineal infection
- incision site
- UTI
- strep.B
- uterine infection
- mastitis / breast abscess
- STD/STI
72
This type of bacteria is colonized in the genital and GI tracts and urethra
Group B Streptococcus
73
Why is Group B Streptococcus bacterial infection problematic during pregnancy?
- increased risk for premature labour
- risk for perinatal transmission
- increased risk of chorioamnionitis and sepsis
- increased risk for PROM
74
GBS (strep) can be transmitted or acquired by aspiration to the babe. What are the signs and symptoms of early onset GBS?
- pneumonia
- apnea
- sepsis
- shock
75
Late onset GBS (Strep) leads to ________
meningitis
76
How can the transmission of GBS (strep) to the babe be prevented?
-identify those with GBS (vag and rectal swab at 35-37 weeks)
77
Under what circumstances is it appropriate to treat mom with GBS with antibiotics in labour?
- T >38
- PROM >18hrs
- previous infected baby
- pre-term labour
* If incomplete abx in labour, observe mom and babe for s&s of infection
78
What are the most common sites for DVT?
- saphenous vein
| - pelvic vein
79
What causes DVT?
- hypercoagulability
- venous stasis
- injury to the blood vessels
80
What associated factors increase the risk for DVT?
- hydramnios
- preeclampsia
- operative births
- hx of clots
- vericose veins
- obesity
81
How can you prevent inversion of the uterus?
- wait for signs of separation (gush, contracting uterus)
| - use controlled cord traction
82
How do you intervene for a patient who's uterus is inverted?
- call for help
- put back in
- call Doctor
83
What tool is used to assess postpartum pregnancy?
Edinburgh Postnatal Depression Scale
84
What puts an individual at an increased risk for developing postpartum depression?
- personal or family hx
| - PP depression with previous pregnancies
85
What mental health disorder puts a mom at increased risk for postpartum psychosis? How is this treated?
bipolar disorder, treated with pharmacological management
86
Describe postpartum psychosis
onset- 72hrs to 4weeks pp, lasting 1 day to 1month or beyond
- treated with hospitalization, meds and supportive care
* While maternal, neonatal and infanticide are rare, pp psychosis do increase the risk
87
If a mom suffers form postpartum PTSD, what might this look like? What might be the consequences of this?
- feeling numb, dazed, flashbacks, intrusive thoughts, difficulty thinking or sleeping
- dysfunction, impaired bonding, avoidance of childbearing
88
How is PP PTSD treated?
- discuss the event and compare to reality
| - supportive pharmacological and psychotherapy
